Surgery accomplished with the use of energy discharging probes is well known. Examples of such energy discharging probes include surgical instruments operating upon the knee and laparoscopes for operative insertion into the abdomen. These instruments are all inserted into an incision and thereafter manipulated proximally (exterior of the patient) to move their distal end (interior of the patient) to the operating disposition at the intended internal site of the surgery.
The body, however, contains many surgical sites where the insertion of a probe is constrained. That is to say, that although the probe is conveniently inserted along a constrained path at many surgical sites, it cannot be manipulated proximally to achieve the desired surgical result because the space into which it was inserted is so restrictive it does not otherwise accommodate gross side-to-side motion (or even rotation) of the probe without significant risk of injury to vital structures. In other words, once the surgical probe is in place, it cannot be moved about easily, other than the original "in-and-out" motion by which insertion to the surgical site occurred in the first place. Transecting of the transverse carpal ligament for the relief the carpal tunnel syndrome is an example of such surgery where movement of a probe is severely restricted.
The carpal tunnel syndrome is a well established symptom complex resulting from median nerve compression at the wrist. Referring to FIGS. 1 and 2, the carpal tunnel T is located on the palmar aspect of the wrist (carpus or wrist bones) (see aspect of FIG. 1) between the distal wrist flexion crease 14 and roughly the mid palm. The anatomy of the carpal tunnel in its contents is shown in relation to the surface structures in the section of FIG. 2. The median nerve 20 is superficial on the radial aspect of the flexor tendons 24 and branches, just distal to the distal border of the transverse carpal ligament L. Those familiar with anatomy will know that four superficial flexors, four deep flexors, the flexor pollicis longus and the median nerve normally travel through this tunnel.
Three of four boundaries of the carpal tunnel are essentially inelastic (see bones B in FIG. 2). The dorsal, radial, and ulnar borders form the U-shaped configuration which is open palmarly. The fourth side, the palmar side, consists of the transverse carpal ligament.
Any condition, systemic or local, which reduces the normal available cross-sectional area of the carpal tunnel--either by increasing the volume of contents or by decreasing the diameter of the tunnel--causes local constriction of the median nerve (the structure most sensitive to compression). The most common symptoms are those of sensory abnormalities in the median nerve distribution of the hand. See 20, FIG. 1. These include hyperesthesia (acute irritating hypersensibility), paresthesia (burning, tingling "pins and needles" sensation), hypoesthesia (decreased sensibility) and pain.
Surgery is indicated for cases of carpal tunnel syndrome retracting to conservative care, particularly those with obvious muscle atrophy of the median enervated thenar muscles. The purpose of the surgery is two-fold: (1) to release external pressure on the median nerve and (2) to diagnose and treat the pathology responsible for the nerve compression.
The tarsal tunnel has surgical problems analogous to the carpal tunnel.
As is well known to those specializing in hand surgery, problems exist upon surgery in the wrist. Simply stated, the joint interfaces at the wrist manifest with problems such as tears in the triangular fibrocartilage, chondromalacia, arthritis, irregularity in the articular surface, synovitis, and loose bodies floating in the joint, causing pain.
The elbow is analogous to the wrist, except that the elbow does not have triangular fibrocartilage or the problems associated with it.
Similarly, the ankle has surgical problems comparable to those of the elbow.
The temporomandibular joint has surgical problems similar to those of the wrist, with the additional complication associated with disease states of the articular disc (meniscus), and scar tissue adhesions.
Conventional treatment as performed in other joints (i.e., the knee) is difficult or prohibitive in the wrist, ankle, elbow, and temporomandibular joint because of the severe limitation of space within these joints, making the positioning of multiple visual/therapeutic devices to the injury site impossible without causing iatrogenic injury.
Breast surgery is another procedure where the apparatus and process of this invention is applicable.
Breasts are augmented or made larger by an implant. The implant is a foreign body. All foreign bodies have scar tissue deposited around them. When the scar tissue is deposited and either contracts or shrinks, the breast implant becomes hard. This causes a disfigurement in the breast shape, and if the scar tissue grasps a nerve or if an otherwise hard distended implant impinges upon a nerve, this causes pain.
Conventional treatment includes two procedures. The first is closed capsulotomy where one squeezes the breast and bursts the breast capsule. This is ineffective because the implant can also pop. This procedure can also causes pain to the patient and pain to the surgeon.
The second procedure is the so-called open capsulotomy. In this procedure an incision is made, and the surgeon deflates and removes the implant under direct inspection. Thereafter, surgical entry is made into the evacuated capsule with at least two or three instruments, and the surgeon cuts the capsule, recreating a large pocket. Thereafter, a new implant is inserted. This latter procedure increases cost, prolongs the operation, and increases morbidity, including the potential for bleeding (and scarring).
Laser surgery has been used in other body sites before. Most commonly, and analogously with respect to this invention is laser surgery on various joints within the body, especially on the knee.
Most sites in the body have the advantage of providing proximal manipulation of the operating instrument, especially the knee. That is to say, the surgeon by the manipulation of the device external to the patient, gets the operative end of the device internal of the patient to move to an operating position. Another example of such an instrument is a laparoscope, an instrument utilized in operations on the abdomen and, in particular, the gallbladder.
Typically, the laparoscope is a multichannel instrument carrying a fiber probe for discharging surgical energy in one channel and an optical viewing fiber in another channel. Additionally, it is common with such devices to provide for suction, irrigation, and a tube for the insertion and removal of various tissue grasping devices. There are usually done through separate openings leading to the operation site.
In a laparoscope, the energy discharging fiber at the end of the probe can be moved within the field of view provided by the fiber. The energy discharging fiber is arrayed parallel to the longitudinal axis of the probe. At the tip of the probe, there is defined a fiber end holding section of the probe which raises and lowers with respect to the elongate axis of the probe.
In surgery, the physician first points the entire probe in the direction of or at the surgical site. The surrounding anatomy of the patient is conformable; it permits the probe to be moved relative to the patient until the operative tip is near the surgical site. Thereafter, and when the probe is adjacent to the surgical site, the surgeon raises or lowers the fiber end holding section of the laparoscope to the angle necessary to direct the surgical energy discharged from the tip of the fiber. Thereafter, the entire probe is rotated to direct the energy discharging fiber to the correct angle relative to the axis of the probe for the surgery.
The reader will understand that the above-mentioned surgical techniques for parts of the body where a probe may be manipulated proximally are simply not applicable to restricted operating sites in the body where the probe is constrained, particularly carpal tunnel surgery, tarsal tunnel surgery, surgery of the wrist, ankle or elbow, surgery of the temporomandibular joint, and surgery on breast capsules after augmentation. Moreover, in the case of breast implants, actual surgery between the interface of the implant scar tissue capsule and the implant must occur without damage to either the implant or the anatomy adjacent the capsule.